Sometimes a paper is published that makes you stop dead in your tracks. In this post-truth era we are so used to reading headlines that sound too good to be true that we just skip over them. But this paper was published in the reputable New England Journal of Medicine.
I’m currently working in a rural Paediatric HDU in Kenya, and removed from the incredibly high-level (and free) health care we can access in Australia. I’m reminded that while we see and treat many sick children each day in our tiered health care system in Australia, the children we treat are really the tip of an enormous global child health iceberg.
Just like that feeling of starting your internship or your first ward shift as a registrar, I anticipated the first few weeks working here to be an adjustment. But what I hadn’t quite prepared myself for – despite a decade working in development economics and community health projects across East and West Africa – was the incredibly, unjustifiably and unfairly high child mortality rates.
Here in Kenya, we have 8am handover meetings, just like we do at my tertiary teaching hospital in Australia. The night staff present their cases, and consultants quiz and often intimidate in their teaching. And just like at home, we start with the admissions, then the high acuity cases. But that’s where the familiarity ends: the third part of every morning meeting is consumed with then discussing the mortalities. Often one case, sometimes up to five – and so many are such simple and avoidable deaths.
Almost six million children worldwide die before their 6th birthday each year. That’s 16,000 children dying prematurely every day – 680 every hour – or 12 perishing every, single, second. The vast majority of these deaths are completely preventable. And for no reason aside from a geographic lottery, a child who is unlucky enough to enter the world from the womb of a mother living in sub-Saharan Africa is 15 times more likely to be one of those mortality statistics than is a child in Australia.
While we are fortunate to consider a clinical trial enrolment or the latest immunotherapy for a child presenting with malignancy in Australia, an intermittent supply of pethidine is all that is available here to palliate a child presenting with simple leukaemia. Burns that are routinely referred to tertiary specialist units in Australia receive nothing more than simple dressings and completely inadequate analgesia; ubiquitous wound infections leave permanent scars on subsequently deformed little limbs. A simple case of gastroenteritis that would score a trial of fluids in our well-resourced Emergency Department is a death sentence to the severely malnourished baby who is being fed unpasteurised cow’s milk due to a lack of maternal milk supply. Exhausted and weak mothers rest their head by the side of their sick children all day, hoping for a miracle. The wails from mothers whose children die are deep, pained and relentless; echoing through the ward revealing a soul full of pain.
The Lancet has recently updated the comprehensive and excellent epidemiological data of the Global Burden of Disease study, examining the trends that constitute the large, hidden, floating iceberg at the depths of the world that is the avoidable morbidity and mortality afflicting so many children. While child mortality rates have diminished globally over the past five decades, increases in mortality have concurrently occurred in some age groups and inequalities within countries are growing. Sub-Saharan Africa remains the most dangerous place to be born, with one child in every 13 dying before their 5th birthday. Equating this to an Australian preschool setting, that’s one to two children from each preschool class dying before they even have the opportunity of starting primary school.
While we excel in discovering new treatment options for rare diseases in high-income settings, it is worth remembering that by far, across the world, the huge volumes of children dying every day are succumbing to simple diagnoses that need simple medicine. The number one cause of death in children under five globally remains simple lower respiratory tract infections, followed by diarrhoeal diseases and malaria. In neonates, neonatal encephalopathy due to birth asphyxia, prematurity and sepsis predominate as the top causes of death; together causing an enormous burden which is largely preventable. I see these statistics on a daily basis – the midwife carrying in another seizing baby who hasn’t been able to be monitored in delivery due to a lack of staff (often in the realm of ten deliveries per midwife per shift); the toddler whose extremities I feel become cooler and cooler as their gram-negative sepsis overwhelms the highest antibiotic option I have access to on the ward; the neonate with meconium aspiration syndrome who desperately needs HFOV and nitric oxide but is struggling to breathe in a facility that can offer nothing beyond high-flow oxygen.
Cause of death in children <5 years; 2000-2015. Source: Global Health Estimates Technical Paper WHO/HIS/IER/GHE/2016.1
As paediatric health professionals, we have an innate responsibility to address health inequality on a local and global scale. In Australia, health outcomes continue to be affected by wealth, with disparate familial incomes affording faster access to elective procedures for those with private health cover, while limited household budgets restrict food options and result in iron deficiency that may impact learning outcomes for a child in school. With child mortality rates in Indigenous Australian children persisting at almost double that of non-Indigenous children, there are a multitude of ways that we, as health professionals, can advocate for change and improving equal health care and outcomes across Australia.
So what can you – as one doctor, in this vast ocean filled with icebergs – do? Be vocal about health inequalities in our own nation and use your position to advocate to Close The Gap. Encourage others to gain an understanding of global health and inequity issues, and to appreciate how our world has evolved to be such an inequitable place (I previously wrote about the West’s role in creating sub-Saharan Africa’s current state here). Familiarise yourself with the UN’s Sustainable Development Goals and advocate for our leaders to support them. Lobby the Government by making a stand over our deplorable treatment of refugees, or to increase our paltry international aid budget. Gain knowledge in understanding the complex social determinants that trap a child in poverty.
And don’t underestimate the difference you can make in using your skills in developing countries, either by contributing to long-term research or clinically, even if just for a short time. In Malawi’s main tertiary hospital, the infant mortality rate dropped significantly through the vision of one paediatrician who instigated simple measures such as kangaroo care, low-cost CPAP solutions and antenatal steroids and antibiotics for preterm labour. Use a week or two of your annual leave to assist in teaching APLS courses or the “Helping Babies Breathe” programme in low- and middle-income countries, or volunteer with organisations such as MSF (or if, like me, you have an entourage of children to consider – there are others that accept children as part of family placements, like the Red Cross or Mercy Ships). You can search for a country and length of time that would best suit your availability here or here. But bear in mind that while sharing your skills and advocating for improved global child health equality is admirable, medical ‘voluntourism’ is not always a good thing and you will – most likely – gain more (on a personal level) than you can give. Focus on strengthening local health systems, not replacing them; and addressing the root cause of global health inequalities by considering the social determinants of health. Speak up as a vocal voice to advocate change. Piece by piece, as Paediatric Doctors across the world, we can together chip away at the enormous child mortality iceberg and with sustained input, we can make an impact within our lifetime.
Our community is made up of health care folks that do hard things, go the extra mile, work on themselves and their knowledge so that patients get better outcomes. We’re not good all the time. We make mistakes, forget stuff, get grumpy or emotional, slide into tribal behaviour. But we’re working on it. So when someone comes along and shines a light on what’s happening outside our normal frame of practice, shows us patients that can’t get care, who are needlessly dying or suffering, it makes us uncomfortable. We want to do something.
Sometimes I get asked to be the person that turns on that torch, the person that makes everyone else uncomfortable, most recently at the excellent DFTB17. I try to do this with balance, to show another context, but also not to make people feel helpless or shocked. Sometimes I get it right, sometimes not. Without fail though, at least one person always asks me afterwards a variation of ‘What can I do?’